Acceptability, feasibility and appropriateness of intensified health education, SMS/phone tracing and transport reimbursement for uptake of voluntary medical male circumcision in a sexually transmitted infections clinic in Malawi: a mixed methods study

Introduction

Uptake of voluntary medical male circumcision (VMMC) remains a challenge in many settings. Innovative implementation strategies are required to scale-up VMMC uptake.

Methodology

RITe was a multi-faceted intervention comprising transport reimbursement (R), intensified health education (IHE) and SMS/Telephone tracing (Te), which increased the uptake of VMMC among uncircumcised men with sexually transmitted infections (STIs) in Malawi. Using a concurrent exploratory mixed-method approach, we assessed the intervention's acceptability, feasibility and appropriateness among men with STIs and healthcare workers (HCWs) at Bwaila District Hospital. Participants completed Likert scale surveys and participated in-depth interviews (IDIs) and focus group discussions (FGDs). We calculated percentages of responses to survey items and summarized common themes using thematic analysis. Median scores and interquartile ranges (IQR) were calculated for acceptability, feasibility and appropriateness of each strategy at baseline and end-line and compared using the Wilcoxon signed rank test.

Results

A total of 300 surveys, 17 IDIs and 4 FGDs were conducted with men and HCWs between baseline and end-line. The mean age for men in the survey was 29 years (SD ±8) and most were married/cohabiting (59.3%). Mean age for HCWs was 38.5 years (SD ±7), and most were female (59.1%). For acceptability, participants agreed that RITe was welcome, approvable, and likable. Despite participants agreeing that RITe was a good idea, culture and religion influenced appropriateness, particularly at baseline, which improved at end-line for Te and R. For feasibility, HCWs agreed that RITe was easy to implement, but expressed concerns that R (end-line median = 4, IQR: 2, 4) and Te (end-line median = 4, IQR: 4, 4), were resource intensive, hence unsustainable. Interviews corroborated the survey results. Participants reported that IHE provided important information, Te was a good reminder and R was attractive, but they reported barriers to R and Te such as electricity, limited access to phones and distrust in the government.

Conclusions

The RITe intervention was acceptable, feasible and appropriate. However, culture/religion and structural barriers affected perceptions of appropriateness and feasibility, respectively. Continued awareness raising on VMMC and addressing setting-specific structural factors are required to overcome barriers that impede demand-creation interventions for VMMC.

Study registration

ClinicalTrials.gov identifier: NCT04677374. Registered on December 18, 2020.

Effectiveness of an intervention to increase uptake of voluntary medical male circumcision among men with sexually transmitted infections in Malawi: a preinterventional and postinterventional study

OBJECTIVE

To evaluate the effect a multistrategy demand-creation and linkage intervention on voluntary medical male circumcision (VMMC) uptake, time to VMMC and predictors of VMMC uptake among men with sexually transmitted infections (STIs).

DESIGN

Pragmatic preinterventional and postinterventional quasi-experimental study combined with a prospective observational design.

SETTING

A public and specialised STI clinic in Lilongwe, Malawi.

POPULATION

Uncircumcised men who presented to the STI clinic.

METHODS AND INTERVENTION

The intervention consisted of transport reimbursement ('R'), intensified health education ('I') and short-messaging services/telephonic tracing ('Te'), abbreviated (RITe). A preintervention phase was conducted at baseline while RITe was rolled-out in the intervention phase in a sequential manner called implementation blocks: 'I' only-block 1; 'I+Te'-block 2 and RITe-block 3.

MAIN OUTCOME MEASURES

Primary: VMMC uptake and time to VMMC for the full intervention and for each block. Secondary: predictors of VMMC uptake.

RESULTS

A total of 2230 uncircumcised men presented to the STI clinic. The mean age was 29 years (SD±9), 58% were married/cohabiting, HIV prevalence was 6.4% and 43% had urethral discharge. Compared with standard of care (8/514, 1.6%), uptake increased by 100% during the intervention period (55/1716, 3.2%) (p=0.048). 'I' (25/731, 113%, p=0.044) and RITe (17/477, 125%, p=0.044) significantly increased VMMC uptake. The median time to VMMC was shorter during the intervention period (6 days, IQR: 0, 13) compared with standard of care (15 days, IQR: 9, 18). There was no significant incremental effect on VMMC uptake and time to VMMC between blocks. Men with genital warts were 18 times more likely to receive VMMC (adjusted relative risk=18.74, 95% CI: 2.041 to 172.453).

CONCLUSIONS

Our intervention addressing barriers to VMMC improved VMMC uptake and time to VMMC among uncircumcised men with STIs, an important subpopulation for VMMC prioritisation.

TRIAL REGISTRATION NUMBER

NCT04677374.

Improving STI and HIV Passive Partner Notification using the Model for Improvement: A Quality Improvement Study in Lilongwe Malawi

Background:

In Malawi, passive partner notification is the mainstay method of partner notification (PN). Despite its wide use, the proportion of sexual partners referred for care through this method is very low. We aimed to increase the proportion of sexual partner referral through passive PN.

Methods:

We implemented a quality improvement (QI) project at Bwaila STI unit in Lilongwe, Malawi between January and June 2017 using a pre- and post- intervention quasi-experimental study design. Pre-intervention, we conducted key-informant interviews and clinic observations and used the findings to design a QI project using expert opinion. The intervention included three change ideas: early start time of the clinic, shortening of the group health talk and expedited clinic flow for sexual partners. Each change idea was tested twice through 1-week long Plan-Do-Study-Act cycles using the model for improvement (MFI) and then combined and tested twice. Process data were collected and monitored using run charts. Post-intervention, we evaluated the proportion of sexual partners who presented to the clinic, to detect a 10% increase at 95% power and α=0.05, between pre- and post-intervention periods.

Results:

The average duration of the group health talk dropped from 56 minutes to 38 minutes and the duration of clinic stay for sexual partners reduced by 45 minutes (from 1hour 36 minutes to 51 minutes). The average clinic start time improved from 09:02 hours to 08:17 hours. The proportion of sexual partner referral increased by 37% (P=0.04) - from 15.6% to 21.4%. We observed an upward trend in the proportion of sexual partners referred in the post-intervention period.

Conclusion:

The yield of sexual partners through passive PN was improved using a simple QI intervention implemented using the MFI. However, the proportion of sexual partner referral remains suboptimal. More effort is required to increase the proportion of sexual partner referral in Malawi.